Tarnow Articles

Bipolar Disorder in Children by Jay D. Tarnow, M.D.

Introduction

A Progressive Disorder
Can children exhibit symptoms of Bipolar Illness? Recently the media has been reporting on this scientific controversy, which has been raging for the past five years in child psychiatry. It sounds like we now have a defined methodology for diagnosis and treatment of this disorder according to some pundits. But it is not as clear-cut a diagnosis as one might expect. Particularly in regards to children, there needs to be more in-depth understanding of this disorder before leaping into a potentially dangerous course of therapy. The reality is that Bipolar Disorder is a very serious disease that worsens as a person ages. I am concerned whenever the media rushes out with premature news coverage touting break-through discoveries and making definitive statements that the public can easily misconstrue. I also worry about the proliferation of misdiagnosis and over-prescription due to lack of proven efficacy. Because of my concerns regarding this controversy, I am dedicating the Fall issue of our newsletter to the subject of Bipolar Disorder in Children. I hope to clarify existing facts, present some recent research findings, and hopefully shed light on the reasons to proceed cautiously in making this diagnosis.

"Bipolar Disorder is a very serious disease
that worsens as a person ages."

History

When I was in medical training during the early 1970's, the common name for Bipolar Disorder was Manic Depressive Illness, now best described as a spectrum of different disorders at different times in a person's life.

This was considered a rare disorder with symptoms first presenting in adults typically around the age of 30. Studies showed Lithium to be the most effective medication in treating Manic-Depressive patients. We began to see the diagnosis rate soar, doubling each year, as is often the case with newly discovered therapies. It is not unusual for doctors to enthusiastically prescribe something different if it promises a cure or even temporary relief from suffering. And why not? If it works, let's try it!

Key to Spectrum Terms*

BP, NOS = bipolar disorder, not otherwise specified. This could include mania or hypomania only on anti-depressants, recurrent MDD with underlying hyperthymia, or recurrent MDD with a first-degree relative with bipolar disorder.
SA = schizoaffective disorder, bipolar type, can be seen as a more severe version of Manic Depressive Illness. MDD = Major Depressive Disorder
MDE = Major Depressive Episode
Dysthymia = Chronic Mild Depression

Ghaemi SN et al. J Clin Psychopharmacology. 1999; 19:354-361

The DSM-IV Subtypes of Bipolar Disorder

Bipolar I disorder = At least one lifetime episode of manic or mixed disorder and although not required for the diagnosis, at least one lifetime episode of major depressive disorder.
Bipolar II disorder = At least one lifetime episode of hypomanic disorder and at least one lifetime episode of major depressive disorder.
Bipolar disorder with rapid cycling = Meets criteria for bipolar I or bipolar II disorder and Four or more episodes of major depressive disorder, manic disorder, mixed disorder, or hypomanic disorder in any one year.

Research

While additional new medicines have entered the market which have been shown to be helpful for Bipolar Disorder in adults, Child Psychiatrists have been perplexedly studying children who remain very difficult to diagnose and treat via traditional child-centered therapies. Could it be that children also suffer from Bipolar episodes? Might they also benefit from the same drugs? The answers to these questions are not simple.

Now that we have results of long-term studies that followed ADHD children into adulthood, data suggests 10-30% of such children develop Bipolar Illness later in life. Many adult Bipolar patients report that as they look back, their disease process in fact started sometime during childhood or adolescence. To date, our scientific information is not conclusive due in part to the stigma associated with mental illness in general, and the tradition of placing less importance on children's problems which has limited Child Psychiatry research. Fortunately, this has started to change and the evidence is finally coming out (although still incomplete). We need to be careful in interpreting such early data, however.

"...data suggests 10%-30% of such
(ADHD) children develop Bipolar Illness later in life"

A Genetic Disorder?

We can say at this point that Bipolar Disorder is clearly a biological disorder, like ADHD, and that individuals are genetically predisposed. While taking a thorough family history of psychiatric problems constitutes an important part of the diagnostic process, the specific genetics have not yet been completely defined.

Current thinking is that roughly nine genes are involved to bring forth the entire illness. The more of the genes present, the more likely that one will have the disease and the worse its severity. This is called "gene penetrance."

Not every generation of a family susceptible to an illness develops it in the same way. Often, later generations suffer more than earlier ones because of a genetic mechanism known as "trinucleotide repeat expansion." Defective sequences of genes may grow longer each time they are inherited, making it more likely that descendants will come down with the disease.

According to the American Academy of Child and Adolescent Psychiatry, a third of the 3.4 million children who first seem to be suffering with depression will go on to manifest the bipolar form of a mood disorder. Researchers in the field of Early-Onset Bipolar Disorder peg that figure closer to 50 percent. Amid all the dry statistics stand several million suffering children as well as their mothers, fathers, brothers, sisters and grandparents.

Some of these same genes are related to Alcoholism, Schizophrenia, Depression, and Impulse Disorders. That is why patient histories need to be very broad and detailed in nature. Although this sort of information may be difficult to obtain from family members, it is extremely important to see the bigger picture. Some people may have only a few of the genes and it may take the occurrence of certain environmental stresses before they actually develop Bipolar Disorder. The severity is, therefore, related to both the genetic load and the intensity of the environmental stress.

"Not every generation of a family susceptible
to an illness develops it in the same way."

Bipolar Disorder in Adults
• Prevalence: 1.8 to 3.6 million Americans (1.2% - 2.4%)
• Impact:
  • Morbidity
    1/4th of adults hospitalized and an additional 1/4th disabled
    14- yr cumulative loss of productivity
  • Mortality
    9.2-year reduction in life expectancy

Risk Factors that Increase the Chance of Exhibiting Disease

Protective Factors Against Exhibiting Disease

All stressful circumstances of life can have an impact on Bipolar Disorder and its manifestation. Thus, increased awareness, gaining understanding, and creating buffers to stress may alter the severity of the illness or keep it at bay altogether. As shown in the previous chart, environmental stressors include changes in diurnal (sleep) patterns, family dysfunction and disruptions, chaotic lifestyles, and interpersonal conflicts. One stressor that clearly precipitates the emergence and increases the severity of the illness is substance abuse, especially alcohol, marijuana, cocaine, and methamphetamines.

The vulnerable Bipolar brain is very sensitive and reacts on a physical level, whereby stressors kindle the emotional center of the brain. The vulnerable cells start to kindle cells next to them and create an electrical storm, which may stimulate an emotional reaction. This is the reason anti-seizure medications are now being used to suppress the reactivity of brain cells in the emotional areas of the brain, just like they do in motor seizures.

Diagnosis

The diagnosis of Bipolar Disorder in children is a complicated, often difficult one to make. Many psychiatric disorders can present the same symptoms and several medical illnesses resemble Bipolar Illness in their presentation, as shown below.

The accumulated data does indicate that children with these same behaviors or symptoms can have Bipolar Disorder, but it is not a common occurrence. What is so confusing is that about 40% - 50% of patients with Bipolar Disorder can also have other comorbid conditions. So, why is it being diagnosed more often than in past years? First of all, there is an increased awareness of the disorder in children. Without a definitive diagnostic test, however, we have to rely on clinical diagnostic techniques that include a detailed history, behavioral diaries, and careful examination by a well-trained clinician with special expertise. In addition, having an illness that is constantly changing makes it difficult for parents to describe and for clinicians to catch the signs and behavior during an office visit. This is why parent education and good communication with the therapist are key factors.

Similarities of Symptomology

Differential Criteria

Additional Symptoms/Signs Consistent with Bipolar

• Periodic racing thoughts with elation and grandiosity
• Paranoia
• Increased irritability
• Cognitive giftedness
• Hyper-sexuality
• Vivid and disturbed dreams
• Periods of decreased need for sleep
• Anti-depressants can cause mania or rapid cycling
• Increased sexual interest and play at early age
• Periods of general heightened state of sensory arousal

Suggested Reading:

All book links go to Amazon.com

• Raising a Moody Child : How to Cope with Depression and Bipolar Disorder
  Mary A. Fristad, PhD, and Jill S. Goldberg Arnold, PhD
• The Bipolar Workbook : Tools for Controlling Your Mood Swings
  Monica Ramirez Basco, PhD
• Brilliant Madness : Living with Manic Depressive Illness
  P. Duke
• We Heard the Angels of Madness
  Diane and Lisa Berger
• The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder (Revised and Expanded Edition)
  Demitri Papolos and Janice Papolos
• His Bright Light
  Danielle Steele
• The Bipolar Disorder Survival Guide: What You and Your Family Need to Know
  David Miklowitz
• Detour : My Bipolar Road Trip in 4-D
  Lizzie Simon
• An Unquiet Mind : A Memoir of Moods and Madness (Vintage)
  K.R. Jamison